Who shall live?

The demonstration in Seattle 1960-3 that the new technique of dialysis could prolong the lives of patients with end stage renal disease led to a crisis. Both of provision – it was expensive – and ethical. Who should receive this scarce treatment?

An age range of 18-45 was considered at first in Seattle, but soon a series of medical, social and psychological assessments preceded consideration by the ‘Life and Death Committee’. In the UK, a common approach was to take on the next available patient if there was a space: ‘If the dustman comes before the duke, the dustman gets treated’. But older or unfit patients would rarely be referred.

It is tempting to think that these problems have gone away. However most of the world’s population lives in countries which still do not have the capacity to provide dialysis for all who need it. The 2010 Tier 1 criteria for dialysis in the public sector in South Africa were remarkably similar to those 45 years earlier:

Tier 1 – should receive dialysis in the public sector (South Africa 2010)

Commentary

Dialysis was a technological miracle treatment for acute renal failure, first effectively implemented in unlikely circumstances in occupied Holland towards the end of the Second World War. It was then really proven as an acute treatment in the Korean War in 1951. In 1960 in Seattle, Belding Scribner knowingly dialysed a patient with end-stage renal failure, using his new arteriovenous shunt device to access the circulation repeatedly. Initially a curiosity, his small cohort of patients on long-term dialysis slowly grew, creating increasing international interest, and an economic and ethical dilemma.

Extraordinary resourcefulness made the technique available to more people – machine improvements; passing the work of dialysis to fewer and less expensive staff; and finally, the outlandish idea of training patients to treat themselves, at home.

Eventually, publicity about patients dying of renal failure has brought adequate provision to economically advantaged countries. But dialysis may not be best use of scarce resource in countries with lower levels of healthcare provision.

Times when health economics clash with ethics are common, but dialysis for renal failure is a particularly stark example. It became a reference point for thinking through the ethics of how decisions around new treatments should be made; both at a public health level (affordability/ prioritisation), and around individual decisions (should this patient receive the treatment, or that one).

Further info

In 1965 many centres required not only that you were suitable for transplantation, but also that you had a potential living kidney donor. Few saw dialysis as a long-term treatment at that time, but the success rates of transplantation were also very poor.

A sobering 1965 NBC documentary Who Shall Live (YouTube, 55 mins) tells of the transforming effect of dialysis on those who could get it, the brutal consequences for those who didn’t, and describes the cost and political issues behind the policies.